Structured observation summaries : educational interest in the teaching of pulmonology.

BACKGROUND: The structured observation summary (SOS) is a method of active case-based learning, whose diagnosis is known to learners. AIM: To assess the value of SOS in the learning of clinical reasoning in pulmonology among first year students of the second cycle of medical studies. METHODS: This was a descriptive cross-sectional study. Teaching was provided to 3 groups of students in three sessions per group in the staff room of the pneumology department of Charles Nicolle Hospital in Tunis, during the second semester of the 2019/2020 academic year. We compared the scores assigned to a given test before and at the end of the session to assess knowledge acquisition. The students filled out a satisfaction questionnaire at the end of the session. RESULTS: We held 9 tutorial sessions in which 30 learners participated and 78 SOSs were completed. The subjects chosen were respectively tuberculosis, pneumothorax, and fluid pleurisy. After correcting the SOS cards, we saw an improvement in averages and scores during the sessions. Learners found no difficulty in completing the items relating to historical data and physical examination. The section relating to «particularities to report¼ was not completed throughout the sessions. By comparing the scores assigned to the test before and at the end of the session, a statistically significant improvement was noted for the 3 themes with p=0.003, p=0.001, p=0.002, respectively. The response to the satisfaction questionnaire revealed that most students were satisfied with the general learning process (95%). They judged the content of the sessions to be relevant (95%) and felt that this teaching facilitated the process of their clinical reasoning (97%). CONCLUSIONS: The satisfaction recorded by the students regarding this project invites us to extend its scope. However, some changes need to be made to the SOS form.

Extremely preterm infants in Tunisia: Where are we now?

BACKGROUND: Extremely preterm infants are newborns born before 28 weeks of gestation. Survival of these immature newborns depends on resuscitation and the quality of care during hospitalization. OBJECTIVE: To determine survival and neurologic outcomes at2 years after extremely preterm birth. METHODS: It is a retrospective multicentric study in 5 neonatal intensive care units (NICU) in 2012-2013.All live births less than 28 weeks gestation were included. RESULTS: A total of 109 births were recorded. Prenatal corticosteroids were given in 47% of cases. Mean weight was 989g and mean age was 26 weeks gestation. Ninety percent of patients had respiratory distress syndrome and 67% of them needed respiratory support. Surfactant was given to 29% of newborns. The mortality rate atdischarge was 76%.The first cause of mortality was nosocomial infections. At thecorrected age of 2 years, 27% of survivors had abnormal neurologic outcome. CONCLUSION: In our study, survival and neurologic outcomes ofextremely preterm infants were poor.In this high-risk population, improving perinatal care remains a challenge to improve long-term outcome in Tunisia.

Evaluation of CIAP (Clarification, Illustration, Application, Participation) as a teaching tool in rheumatology.

INTRODUCTION: The CIAP (Clarification, Illustration, Application, Participation) teaching, was adopted by our faculty since 1988. It allows a pedagogical approach favoring teacher / student contact. It puts the disciple in the center of the work. However, this method has been initiated for a long time, its actual place in our teaching is not yet well established and not all teachers adhere to it because it has never been evaluated before. AIM: To evaluate the CIAP teaching in rheumatology in abarticular shoulder pathology in DCEM1 students. METHODS: A cross-sectional study of students in DCEM1 during the internship at the Kassab institute. Students were informed about the teaching (CIAP) a week before so they could read their corresponding self-teaching module in advance. A pre-test and a post-test were prepared in advance as well as an evaluation of the teaching by the learners. RESULTS: We founded after this teaching, an improvement of the score of the pre-test with a progression of the means statistically significant (p <10-3). Concerning the assessment of CIAP teaching by our learners in terms of relevance in general, organization and implementation, it showed a majority of satisfaction with a predominance of a "2" rating according to the scale of Likert. CONCLUSION: Our work has highlighted a positive impact and a good adhesion of students to the abarticular pathology by the CIAP teaching.

Progress and assessment of a contextualized teaching session of pharmacology.

BACKGROUND: Learning transfer, in medical teaching, remains an essential question and optimizing it is the main preoccupation of every trainer in medical sciences. Some learning methods showed their efficacy as the contextualized learning in the framework of a professional activity or in a situation recalling it in a realistic manner. AIM: To describe steps of planning and progress of a session of clarification, illustration, application et participation (CIAP) of pharmacology teaching students from second cycle of medical studies (DCEM) and to assess the session. METHODS: We performed a descriptive transversal study in April 2017 in the Faculty of Medicine of Tunis. Our work was composed of two parts. The first part consisted in a description of the preparation and the progress of the CIAP session entitled antiepileptic drugs, which is comprised in the pharmacology teaching of the certificate of Neurology to the students of DCEM. The second part consisted in an assessment of knowledge acquisition and the progress of the session by the students. RESULTS: We proceeded to a planning of the session which resulted in a contextualized teaching and induced an active participation and an interactivity of the students. Comparison of the results of the pretest and the posttest showed a statistically significant difference in terms of good responses. The assessment of the session progress was good. CONCLUSION: Our study demonstrated the feasibility of a session of contextualized teaching session or CIAP of pharmacology and its input in terms of knowledge to the students.

Evaluation of a CIAP session for students in Medicine, Pediatrics module.

BACKGROUND: Teaching by the Clarification, Illustration, Application and Participation of Students (CIAP) approach is a method of participatory pedagogy that helps active learning to help the learner understand and integrate the new Knowledge to be able to apply them. The objectives of this work were to describe the conduct of a CIAP session and to evaluate this method of learning among students. METHODS: The session took place in a room in the Forensic Medicine Department of the Charles Nicolle Hospital in Tunis on April 18, 2017 for 60 minutes. Our population was made up of DCEM2 students undergoing pediatrics and neonatology at the Charles Nicolle Hospital. The chosen topic was post-infectious acute glomerulonephritis. The assessment consisted in a written test given at baseline before the teaching sessions and repeated immediately afterwards. Students were also asked to grade the quality of the teaching received. RESULTS: In total, 13/22 students were present. Clarifications were given at the request of the students. The illustration showed capillary proliferation and extra-capillary proliferation. Clinical cases have sparked a lot of interaction. All the students participated in the session: seven of them participated actively, the other six were solicited to participate. Pre-test scores varied from 2/10 to 7/10. Post-test scores ranged from 4/10 to 10/10. The mean score for the pre-test was 4.61 ± 1.6 and, the mean score for the post-test was 8.23 ± 2.31 / 10, the difference being statistically significant (p = 0.03). For students, the choices of educational objectives were relevant and were achieved, the session was coherent with the professional reality and brought new knowledge. The majority of students felt that there was good interaction. All students were satisfied with listening to the teacher and her answers to their questions. All students reported that the CIAP session provided them with a better clarification of the theoretical course, a sufficient illustration, and enabled them to participate actively in teaching. The students reported that there was a good application of the theoretical course. CONCLUSION: The CIAP session improved student knowledge. The students were generally satisfied with this teaching.

In-hospital mortality of very preterm infants in a Tunisian neonatal intensive care unit: Prevalence and risk factors.

BACKGROUND: Prematurity is a major public health problem and it's associated with a high mortality and morbidity. In Tunisia, few investigations studied this area. AIM: To determine the rate and the risk factors of in-hospital mortality of very preterm infants. METHODS: We conducted a retrospective monocentric study. We included all premature Infants born at less than 326 weeks of gestation (< 33 Weeks) without major congenital anomalies admitted from January 2011 to December 2012 in the neonatal intensive care unit (NICU) of Charles Nicolle Hospital (Tunis-Tunisia). To determine in-hospital mortality related risk factors, we created and compared two groups:  group of "Survivors" until discharge from our hospital and group of "Dead" before discharge. Multivariable logistic regression models were used to assess the association between risk factors and in-hospital mortality. P-value < 0.05 was considered statistically significant. RESULTS: During the study period, 7606 livebirths (LB) were recorded; among them 113 were very premature infants. The prevalence of high prematurity was 1,4 % LB. Very premature infants were divided in 24 extremely preterm infant (13%) and 89 moderately preterm infants (87%). Mean weight at admission was 1338g (±349g) and the mean gestational age was 30 weeks (±1,7). The mean hospital stay was 26 days (±17days) with an average weight at discharge of 1942g (±249). Neonatal morbidity was mainly caused by respiratory distress (42%), early neonatal anemia (64%), intraventricular hemorrhagea (15%), associated-care health infection (37,6%). In hospital mortality rate was 32 %. Mortality risk factors identified through multivariate analysis were: extreme premature infant (p<0,05), extremely low birth weight (p<0,01) and circulatory disorders (p<0,05). CONCLUSION: Very preterm infant represented 1,4 % of all live births. The mortality rate of very premature infant is still high and mainly associated to neonatal respiratory distress. Improving prevention and neonatal management still very required.

The script concordance test as a tool to evaluate clinical reasoning in neonatology.

BACKGROUND: Script concordance test aims to evaluate knowledge organization, which represents an essential component of the clinical competence. OBJECTIVE: To build a script concordance test and demonstrate its relevance in the evaluation of Neonatology skills. METHODS: A script concordance test including 20 vignettes and 20 items, was provided to 52 fourth year medical students and 11 family medicine interns. RESULTS: Script concordance test scores obtained by experts were higher then those obtained by students and family medicine interns. The scores (out of 100) were 82.52 ± 7.35 CI95% [77.26-87.78] for the experts, 58.52 ± 9.72 CI95% [55.82-61.23] for the students, and 63.17±11.36 IC95%  [55.53-70.81] (p<0.0001) for the interns. CONCLUSION: Our data suggest that script concordance tests could be used to assess the acquisition of clinical reasoning among fourth year medical students in neonatolgy.

Prevalence and outcomes of thrombocytopenia in a neonatal intensive care unit.

Background Thrombocytopenia is a common clinical problem in neonatal intensive care units, affecting about 20 to 35% of all admitted neonates. Even most episodes are mild or moderate, severe episodes could be life-threatening or responsible for sequelae. Objectives The aims of this study were to describe the prevalence, clinical diagnoses, and to determine risk factors for poor prognosis of thrombocytopenia in a neonatal intensive care unit. Methods We carried out a retrospective study in the neonatal intensive care unit of Charles Nicolle Hospital of Tunis, a tertiary neonatal care center, over a four years period (January 2010 to December 2013). All Neonates with at least one episode of confirmed thrombocytopenia were included. Poor prognosis was defined as death or intraventricular hemorrhage ≥ grade 2 in survivors. Results Of 808 admitted neonates, one hundred (12.4%) had presented at least one episode of confirmed thrombocytopenia, and 12 had presented two episodes of thrombocytopenia. A total of 112 episodes of thrombocytopenia were collected. Thrombocytopenia occurred in the first 3 days of life in 74.1% of cases. Thrombocytopenia was mild in 22.3%, moderate in 36.7% and severe in 41%. Intrauterine growth restriction was the most common cause of early thrombocytopenia. Nosocomial sepsis was the most common cause of late thrombocytopenia. We found that the outcomes of thrombocytopenic neonates depend on, birth weight, gestational age, platelet count, and the underlying cause. Conclusions Thrombocytopenia in neonates can be life-threatening, appropriate diagnosis, preventive and therapeutic approach is necessary to prevent death or neurological impairment.

Errors in preparation and administration of parenteral drugs in neonatology: evaluation and corrective actions.

BACKGROUND: The medication iatrogenic risk is quite unevaluated in neonatology Objective: Assessment of errors that occurred during the preparation and administration of injectable medicines in a neonatal unit in order to implement corrective actions to reduce the occurrence of these errors. METHODS: A prospective, observational study was performed in a neonatal unit over a period of one month. The practice of preparing and administering injectable medications were identified through a standardized data collection form. These practices were compared with summaries of the characteristics of each product (RCP) and the bibliography. RESULTS: One hundred preparations were observed of 13 different drugs. 85 errors during preparations and administration steps were detected. These errors were divided into preparation errors in 59% of cases such as changing the dilution protocol (32%), the use of bad solvent (11%) and administration errors in 41% of cases as errors timing of administration (18%) or omission of administration (9%). CONCLUSION: This study showed a high rate of errors during stages of preparation and administration of injectable drugs. In order to optimize the care of newborns and reduce the risk of medication errors, corrective actions have been implemented through the establishment of a quality assurance system which consisted of the development of injectable drugs preparation procedures, the introduction of a labeling system and staff training.

Acute neonatal appendicitis in a preterm.

Acute neonatal appendicitis is very rare in the neonatal period. It is usually associated with comorbidity including prematurity. Symptoms are non-specific. The prognosis is marked by high risk of mortality and morbidity. Here, we report a case of preterm new born who presented with sepsis, apnoea, and digestive signs. The laparotomy revealed perforated appendicitis complicated with peritonitis.

Isolated anti-Ro/SSA thrombocytopenia: a rare feature of neonatal lupus.

We report a rare case of isolated thrombocytopenia related to anti-Ro/SSA antibodies. The mother was followed for unlabeled familial thrombocytopenia. The mother had positive anti-Ro/SSA antibodies. She was asymptomatic without skin lesions or other criteria neither of systemic lupus erythematosus nor other connective tissue disease. Pregnancy was uneventful. The postnatal examination was normal. On the first day of life, blood cells count showed thrombocytopenia at 40 x 10(9)/L. Within the second day of life, platelet level dropped to 20 x 10(9)/L. The management of thrombocytopenia included platelet transfusion and human immunoglobulin infusion. On the fifth day of life, there has been a drop in platelet count to 10 x 10(9)/L requiring renewed platelet transfusion and human immunoglobulin infusion. On the 10(th) of life platelets rate was stable around 60 x 10(9)/L. The infant had no evidence of cardiac, dermatologic or hepatobilary involvement initially or throughout follow up.

Congenital cystic adenomatoid malformation of the lung: two case reports.

BACKGROUND: Congenital cystic adenomatoid malformation (CCAM) is a rare embryonic developmental abnormality with an incidence of one in 25 000 to 35 000 pregnancies. With advances in antenatal ultrasonographia (USG), CCAM has been increasingly diagnosed. After birth, the clinical appearance of CCAM can vary from immediately postnatal respiratory distress, to an incidental finding on chest radiography. AIM: To report two additional cases with CCAM different in clinical features. CASE REPORTS: The first case was a boy in witch diagnosis was suspected by antenatal USG; he was born at 37 weeks of gestation by cesarean section because of severe toxemia, and presented immediately respiratory distress. The chest x ray and computed tomography scan (CT scan) revealed a right CCAM. The second case was also a boy of an inducted threefold pregnancy, born at 30 weeks by cesarean section. He presented immediately respiratory distress. The diagnosis of a right CCAM was confirmed by clinical and radiological findings in postnatal period. CONCLUSION: The two cases described in this report show the disparity in clinical features of CCAM. Nowadays, antenatal echotomography can establish the diagnosis allowing optimum management.

Pallister-Killian syndrome with additional manifestations of cleft palate and sacral appendage.

AIM: Reppor of a rare congenital abnormalities. OBSERVATION: We report a rare case of Pallister-Killian syndrome in a 33 weeks gestation infant. In addition to the characteristic phenotype, this patient had a cleft palate, diaphragmatic hernia and sacral appendage. These additional manifestations are not among the Pallister-Killian syndrome's features. The diagnosis was made in antenatal period by cytogenetic studies and showed mosaic 47, XY+i (12p). Presence of diaphragmatic hernia makes this syndrome, prenatally letal, similar to the Fryns syndrome and then requires skin biopsy and fibroblast chromosome examination for cytogenetic diagnosis.

[Postpartum levels of glycosylated hemoglobin in mothers of large baby: a prospective study]. / Interet du dosage de l'hemoglobine glyquee (HBA1C) en postpartum chez les meres des nouveau-nes macrosomes.

BACKGROUND: The delivery of a large baby may indicate that the mother had abnormal glucose tolerance during pregnancy. Glycosylated hemoglobin (HbA1c) concentration might be expected to identify women who had high blood glucose concentration before delivery. AIM: The aim of this study was to identify retrospectively, gestational diabetes in mothers of large baby and determine the HbAlc cutoff value. METHODS: HbA1 was measured in 216 patients within the first three days of postpartum: 100 had large babies: weighing over than 4000 g and 113 had normal- sized babies (control group). We exclude mothers who had preterm, hypotrophy baby, stillborn, and diabetic mothers. RESULTS: The mean concentration of HbA1c was significantly higher in group with large babies than in group control (6.17% + 085 vs. 5.17 + 0.57 t = 9.78 p < 0.001). The value of HbAlc = 5.85%, evaluated by ROC curve, was considered as risk factor of macrosomia and then gestational diabetes. 83.5% of mothers with large babies had HbA1c ? 5.85 vs. 7.8% of those with normal sized babies (p < 0.0001). No other significant differences were found between the two groups in other parameters. CONCLUSION: HbA1c level may be of value as a postpartum screen for unrecognized diabetes and may help discriminate between a constitutionally large but otherwise normal newborn and a large infant of a diabetic mother. HbA1c measurements should be obtained in women with large babies, and, if upper than cutoff value found by curve ROC: 5.85%, maternal and fetal surveillance is recommended.